Insights

CMS Announces Pre-Claim, Probe Reviews Right Before the New Year

Posted on Thursday, December 29, 2016 3:28 PM

Announcements have been made that CMS’ probe-and-educate review is starting up again and its Pre-Claim Review Demonstration is expanding beyond Illinois. This sounds like trouble for claims scrutiny in 2017. Providers must prepare for what’s to come.

Round 2 of the home health probe-and-educate review began December 15 and will end in about a year, CMS said in MLN Matters article SE1635, dated December 16. All home health agencies with two to five claims in error during the probe’s first round will receive five more ADRs from Medicare Administrative Contractors (MACs) as part of the next round, CMS says.

At this point, CMS hasn’t released data on the probe’s first round. However, 61% of respondents said their agency received at least two denials on HHL’s 2017 Trends Survey.

CMS’ five-state Pre-Claim Review Demonstration is now starting up in Florida beginning on or after April 1, 2017.

After extreme backlash from the home health industry, CMS responded in late 2016 to the objections about the demonstration with a series of reports that the program has generated. The data proved the following:• Pre-Claim Reviews aren’t resulting in high denial rates• Pre-Claim reviewers are responding to submissions well within the required timeframes• Nearly 83% of Pre-Claim Review requests during the demonstration’s 18th week received a fully affirmed decision

While the home health industry continues to express their fears about the program, CMS plans to continue implementing the review.

Senator Marco Rubio, R-Fla., has spoken against the demonstration.

Once the 90-day grace period is up, agencies must submit claims for Pre-Claim Review. If they don’t, agencies will face a 25% payment reduction for claims deemed payable that did not first receive a Pre-Claim Review decision.

Another cause for concern in 2017 is the recent announcement of a recovery audit contractor (RAC), which will be focused on home health, hospice and durable medical equipment claims.

Performant Recovery Inc. will be paid a percentage of the amount of overpayments recovered.

Previously, the “audit bounty” RACs received led them to concentrate on bigger dollar targets such as hospitals and physicians.Performant is aware of the current issues in home health and hospice audits.

Agencies must expect Performant do the following:• Examine face-to-face documentation• Determine the hospices’ length of stay• Observe the overlap between home health episodes or hospice benefit periods and hospital or other claims, as well as traditional issues related to eligibility

The following actions must be taken to prepare for reviews:• Audit documentation to identify all the needed paperwork is present• Keep a close eye on information about medical necessity• Know your data

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